Application

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Application Let us Put a Profession into Your Hands

Application for Admission

Carlson College of Massage Therapy does not discriminate against race, color, gender, age, nationality, religion, disability or sexual orientation.

This application will not be complete until you submit proof of high school graduation or equivalency, and a $50 application fee (send fee via mail or pay with mastercard/visa over the phone at 319-462-3402).

Applicant Information
First Name:
Last Name:
Address Street 1:
Address Street 2:
City:
State:
Zip Code:	(5 digits)
E-mail:
Cell:
Phone:
Birthdate:
Sex::
Which class are you applying for? (Spring or Fall - Full Time or Part Time - Fall only):
In case of emergency, notify:
First Name:
Last Name:
Daytime Phone:
Evening Phone:
Relationship:
Education
High School:
City/State:
Year of Graduation:
College:
City/State:
Degree:
Post Graduate Study:
City/State:
Degree:
Other Training:
Health Information
Name of Physician:
Address:
Phone:
Do you have any medical problems? If yes, describe:
Are you taking any medications? If yes describe:
Do you have any mental, physical, or learning disabilities? If yes, describe:
Is there anything we should know that could affect your performance as a student? If yes, describe:
Other Information
How did you hear about CCMT? (If friend or former student, please name):
Did you attend an Open House? Yes or No - if yes, when?:
Have you had any training in Massage Therapy? If yes, where & duration of time:
Have you had any criminal arrests? If yes, please give details and dates:
Hobbies, interests, skills, etc.:
Name of reference (No relatives):
Address:
Phone:
Name of reference (No relatives):
Address:
Phone:
If you have any additional comments that you feel would be necessary to submit, please add them here:	Enter comments here!
Please print name in place of signature:
	By checking this box I hereby state all of the above information is true to the best of my ability.

Carlson College of Massage Therapy

11809 County Rd X-28 Anamosa, IA 52205

(319) 462-3402